How to prevent, recognize and manage complications of AF ablation?

Micro-Costing Analysis for the Treatment of Atrial Fibrillation: An Economic Evaluation of the First Italian Experience of Same-Day Discharge Protocol for Cryoballoon Atrial Fibrillation Ablation

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia, and its prevalence is expected to increase further due to the aging population, increasing prevalence of risk factors, improving detection methods, and broadening of catheter ablation indications. Along with limited healthcare resources and bed availability, these reasons led to the development of a same-day discharge (SDD) protocol. The aim of this study was to evaluate the health and economic impact of a routine adoption of same-day discharge after cryoballoon AF ablation. Methods: Consecutive patients with symptomatic and drug-refractory AF scheduled for first-time AF ablation were screened, and if deemed suitable, the SDD protocol was proposed and, if accepted, enrolled in the protocol. Results: A total of 324 patients were screened, and 118 were considered eligible for the SDD pathway. Fifty-two patients accepted the SDD pathway and were included in this study. The analysis showed that the variation in resource consumption associated with cryoablation in SDD is equal to EUR 739.85/patient. The analysis showed that the main cost driver for ordinary hospitalization was represented by the hospital stay, which was calculated to be 36% of the total cost. In total, there was a cost reduction of EUR 38.472 thanks to optimized AF patient management from the standard recovery setting to SDD. Conclusions: SDD after cryoballoon ablation of AF is feasible in selected patients with a standardized protocol.

Excess Bed Days and Hospitalization Costs Associated With 30-Day Complications Following Catheter Ablation of Atrial Fibrillation

BACKGROUND

The incidence and type of complications following catheter ablation of atrial fibrillation have been extensively examined, but the impact associated with these complications on the length of stay and hospitalization costs is unknown.

METHODS AND RESULTS

This cohort study included 20 117 adult patients (mean age 62.6±11.4 years, 30.3% women, median length of stay 1 day [interquartile range 1-2 days]) undergoing atrial fibrillation ablation in financial years 2011 to 2017 in Australia with available cost data from the National Hospital Cost Data Collection, which determines government reimbursement of health services provided. The primary outcome was the costs associated with complications occurring up to 30 days postdischarge adjusted for inflation to 2021 Australian dollars. We used generalized linear models to estimate the increase in length of stay and cost associated with complications, adjusting for patient characteristics. Within 30 days of hospital discharge, 1151 (5.72%) patients experienced a complication with bleeding (3.35%) and pericardial effusion (0.75%) being the most common. On average, the occurrence of a complication was associated with an adjusted 3.3 (95% CI, 3.1-3.6) excess bed days of hospital care (totaling 3851 days), and a $7812 (95% CI, $6754-$8870) increase in hospitalization cost (totaling $9.0 million). Most of the total excess cost was attributable to bleeding ($3.8 million, 41.9% of total excess cost) and pericardial effusion ($1.6 million, 18.2%).

CONCLUSIONS

Complications following atrial fibrillation ablation were associated with significant increase in length of stay and hospitalization costs, most of which were attributable to bleeding and pericardial effusion. Strategies to improve procedural safety and reduce health care costs should focus on these complications.

Institutional Variation in 30‐Day Complications Following Catheter Ablation of Atrial Fibrillation

Background

Complications are a measure of procedural quality, yet variation in complication rates following catheter ablation of atrial fibrillation (AF) among hospitals has not been systematically examined. We examined institutional variation in the risk‐standardized 30‐day complication rates (RSCRs) following AF ablation which may suggest variation in care quality.

Methods and Results

This cohort study included all patients >18 years old undergoing AF ablations from 2012 to 2017 in Australia and New Zealand. The primary outcome was procedure‐related complications occurring during the hospital stay and within 30 days of hospital discharge. We estimated the hospital‐specific risk‐standardized complication rates using a hierarchical generalized linear model. A total of 25 237 patients (mean age, 62.5±11.4 years; 30.2% women; median length of stay 1 day [interquartile range, 1–2 days]) were included. Overall, a complication occurred in 1400 (5.55%) patients (4.34% in hospital, 1.46% following discharge, and 0.25% experienced both). Bleeding (3.31%), pericardial effusion (0.74%), and infection (0.44%) were the most common complications while stroke/transient ischemic attack (0.24%), cardiorespiratory failure and shock (0.19%), and death (0.08%) occurred less frequently. Among 46 hospitals that performed ≥25 ablations during the study period, the crude complication rate varied from 0.00% to 21.43% (median, 5.74%). After adjustment for differences in patient and procedural characteristics, the median risk‐standardized complication rate was 5.50% (range, 2.89%–10.31%), with 10 hospitals being significantly different from the national average.

Conclusions

Procedure‐related complications occur in 5.55% of patients undergoing AF ablations, although the risk of complications varies 3‐fold among hospitals, which suggests potential disparities in care quality and the need for efforts to standardize AF ablation practices among hospitals.